DEE NORTON and KPCAC Multidisciplinary Team (MDT) Authorization

The Dee Norton Child Advocacy Center ("DEE NORTON") and the Kay Phillips Child Advocacy Center (“KPCAC”) are interdisciplinary programs having direct contact with area agencies involved in the protection of children. To serve your child and family better, the interdisciplinary process brings together professionals from the fields of child protective services, mental health, medical, education, legal, law enforcement and others. Cooperation and coordination between the area agencies responding to alleged child maltreatment is the key to the interdisciplinary process.

In order to ensure coordination between these various agencies, the Community Child Abuse Response Protocol (Protocol) was developed, signed and is maintained by representatives of the agency members of the Multidisciplinary Team (MDT). The Protocol outlines the specific response guidelines, roles and responsibilities of each agency involved in the interdisciplinary process. In addition, DEE NORTON and KPCAC have agreements and works with other community agencies that provide services to DEE NORTON and KPCAC clients. A list of all DEE NORTON and KPCAC Community Partner Agencies can be found on the last page of this authorization form.

By signing below, the undersigned voluntarily agrees to participate in the interdisciplinary process and grants permission for written and verbal information regarding the client identified below, his or her family, and/or the undersigned, to be exchanged between DEE NORTON and KPCAC staff and Community Partner Agencies for the purposes of evaluation, treatment, case management follow-up, coordination and problem resolution regarding the identified client and family.

In addition, the undersigned grants permission for written and verbal information regarding the client identified below, his or her family, and/or the undersigned, to be exchanged with additional agencies that may be present during the case management interdisciplinary process and whose representative has signed a statement of confidentiality.

The undersigned further authorizes any verbal or written information exchanged as set forth herein to be entered into the DEE NORTON and KPCAC computerized databases and used for research and program evaluation purposes. Any information so used will not identify the client referenced below or his or her family.

The undersigned understands that there are exceptions to the need for the consent contained herein and that such consent is not required in the event there is suspected child abuse or when a person is a danger to himself/herself or others. In such cases, information may be provided to the Department of Social Services, law enforcement or a mental health agency without the consent of the undersigned.

Additional Informed Consent for Other Agency Involvement: For the purpose of service and treatment coordination, I hereby authorize Kay Phillips Child Advocacy Center and Dee Norton Child Advocacy Center to RECEIVE/RELEASE information from/to:

These authorizations are for the following client/child: (Please print clearly.)

A photocopy of these authorizations shall be considered as effective and valid as the originals. These authorizations are valid for two years from date of signature. BY SIGNING BELOW THE UNDERSIGNED REPRESENTS THAT HE/SHE HAS READ AND UNDERSTANDS THE AUTHORIZATIONS CONTAINED HEREIN AND IS KNOWLINGLY AND WILLINGLY AUTHORIZING THE ACTIVITIES DESCRIBED HEREIN:

Signature of Legal Guardian

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If you are signing as a personal representative of an individual, please describe your legal authority to act for the individual (power of attorney, healthcare surrogate, etc.):

By signing below, I acknowledge that these are the Community Partner Agencies with whom DEE NORTON and KPCAC will exchange information as outlined above in the section titled: Authorization to Release and Exchange Information.

Legal Guardian Signature

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Date: 04/28/2025

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DEE NORTON and KPCAC Community Partner Agencies

Berkeley Community Mental Health Center
Berkeley County Department of Social Services
Berkeley County Sheriff’s Office
Charleston County Department of Social Services
Charleston County Sheriff’s Office
Charleston-Dorchester Community Mental Health Center
Charleston Pro Bono
City of Charleston Police Department
Doors To Freedom
Dorchester Alcohol and Drug Commission
Dorchester County Department of Social Services
Dorchester County School District II
Dorchester County School District IV
Dorchester County Sheriff’s Office
First Judicial Circuit Solicitor’s Office
Goose Creek Police Department
Hanahan Police Department
Harleyville Police Department
Isle of Palms Police Department
Jamestown Police Department
Medical University of South Carolina – Child Abuse Pediatrics (MUSC-CAP)
Moncks Corner Police Department
Mt. Pleasant Police Department
National Crime Victims Research and Treatment Center
Ninth Judicial Circuit Solicitor’s Office
North Charleston Police Department
Ridgeville Police Department
South Carolina Department of Juvenile Justice
South Carolina Law Enforcement Division (SLED)
St. George Police Department
St. Stephen Police Department
Summerville Police Department
Sullivan’s Island Police Department
The Formation Project